Physical Fitness for Those with Ms

LET IN THE LIGHT

PHYSICAL FITNESS FOR THOSE WITH MS

SUPPORTING THE MS CAREGIVER

This program has been made possible by a generous grant from

The Bedolfe Foundation.

APPLICATION FORM

Please complete and return to: Multiple Sclerosis Society of Canada

Grand Erie Chapter

Attn: Bedolfe Committee

P.O. Box 25025

Brantford, ON N3T 1M2

Please read the Bedolfe Grant Program Guidelines and Criteria prior to completing and submitting your application or request a copy from our office by calling (519) 758-5175

Section A – Applicant Information:

Name: ______

Address: ______

Postal Code: ______Phone: ______

May we communicate with you by e-mail? ____ Yes ____ No

If yes please provide your e-mail address here: ______

Are you a member of the MS Society, Grand Erie Chapter____ Yes ____ No

Do you have a Caregiver? ____ Yes ____ No

If you indicated yes, please provide a brief description of your caregiver’s role:

Section B – Self-Declaration

This program provides services, activities or items that contribute to the well being of the person with MS through contributing to their emotional, spiritual, physical and/or social

rejuvenation as well as providing funds to enable primary caregivers of people with MS to maintain their own health and well-being while providing assistance and support to someone with MS and thereby enhance their own quality of life.

Please read and sign the declaration that follows:

I, ______declare that I am an individual who has a diagnosis of MS.

(Your name)

I further declare that I require ______to help care for me.

(Caregiver’s name)

For this reason I require financial assistance with the request identified in this application in order to meet my personal needs or the needs of my caregiver and the information provided in this application is accurate and true.

Signed: ______Date: ______

(Your signature)

Signed: ______Date: ______

(Caregiver signature)

Section C – Funding Request

Please indicate the category of funding you are requesting:

¨  Let in the Light (max $500) will give applicants the opportunity to get a break from the routine of living daily with MS. It might mean tickets to movies, a concert or a play. It could also mean adding something extra (non-structural in nature) to their home and/or yard whether it be enhancing a garden, landscaping or maintenance for a yard, getting paint or wallpaper to enhance your home. You could purchase new drapes, bedspreads or an easy chair to provide comfort. There are many possibilities in this category.

¨  Physical Fitness for those with MS (max. $350) provides those living with MS access to yoga, tai chi, swimming or another fitness program in the community. Studies have shown that the benefits of exercise to people diagnosed with MS include: reduction in fatigue, spasticity and pain as well as improving muscle tone, strength and overall endurance. Chiropractic, naturopathic, osteopathic, physiotherapy, registered massage therapy or treatment from a podiatrist could also be included if these services are not already being covered by a current health service provider or insurance.

¨  Supporting the MS Caregiver (max $150) is designed to support an activity that a caregiver engages in to get a break from the rigours of care giving. It could be a weekly massage, a fitness club membership, go to a movie; bowling or whatever form of relaxation they feel may help them. Respite care is covered through our Client Services Program.

Section C – Funding Request, cont.

Provide a brief description of the specific service, activity and/or purchase for which you intend to use the funding:

Describe how the above request will benefit you as the person with MS or your caregiver.

In other words, how will it……….

¨  Provide you with support for your personal needs

¨  Provide you with a break, time off or relief from your daily routine and/or responsibilities

¨  Contribute to your emotional, spiritual, physical and/or social rejuvenation helping you to have more balance in your life and/or the reserves and resources you need

¨  Other

Identify the source from which you will obtain the service/activity/item(s) identified above:

¨  Let in the Light service/activity/item:______

Amount of Funding Requested: $______

(Note: Requests must not exceed funding limits outlined in the guidelines)

¨  Fitness/activity/item:______

Amount of Funding Requested: $______

(Note: Requests must not exceed funding limits outlined in the guidelines)

¨  Caregiver service/activity/item:______

Amount of Funding Requested: $______

(Note: Requests must not exceed funding limits outlined in the guidelines)

Expected date of service completion (i.e. when do you plan to purchase and utilize the service, activity or item identified in the above request?) ______

Section D – Funding Administration:

Requests will be made on a first come first served basis and will be on a continual basis until the funds for the year have been exhausted.

Upon receipt of your application The Bedolfe Committee will review your submission and qualified applicants will be advised accordingly. Upon submission of receipts or paid invoices related to the approved grant, payment will be processed within 30 days. We would prefer to make direct deposit payments, but a cheque payment is available upon request.

If you would prefer direct deposit please indicate below:

¨  I am currently set up for direct deposit with the MS Society of Canada and authorize use of this information to process my grant payment.

¨  I have attached a completed Direct Deposit Authorization form.

¨  Have your direct deposit details changed since last year? If so a new void cheque is required.

Section E – Acknowledgement of Terms & Conditions:

Disclaimer: The Multiple Sclerosis Society of Canada is not liable for any difficulties with suitability, safety, workmanship and/or maintenance related to services or items purchased with funds provided through this application.

Privacy: The Multiple Sclerosis Society of Canada protects clients’ privacy. The information collected is used to provide services to clients, information about programs and meetings, and to compile anonymous statistical or summarized information for program evaluation and reporting. We may also contact you to request your voluntary participation in a follow-up evaluation for this funding project. Your personal information is shared with authorized individuals and companies outside the MS Society of Canada on a need to know basis, in relation to this application, only if a Release of Information Form is signed by the client.

Please note: A release of information form must be signed by all applicants requesting funding. If there is not a Release of Information form attached to your application form please contact the Grand Erie Chapter Office at 758-5175. A copy of our privacy policy may be obtained by calling 1-800-268-7582 or at www.mssociety.ca.

I acknowledge the above Terms & Conditions as well as the Criteria and Guidelines of the Bedolfe Grant Program and commit that all information provided is true and complete. I accept that the decision of the MS Society of Canada, Grand Erie Chapter Board of Directors regarding my application will be binding and final.

Applicant Signature: ______Date:______

Addendum A – Release of Information Authorization (mandatory)

Release of Information Form:

By completing this form you hereby consent to the collection, use and disclosure of the information that you provided in this application by the MS Society of Canada and/or the Bedolfe Foundation Trustees, as it relates to your application.

I, ______hereby give permission to release pertinent

(Print name)

personal information from the Multiple Sclerosis Society of Canada.

Dated at: ______in the province of Ontario

this ______day of ______, 20 ______.

______(signature) (address)

I, ______have witnessed ______

(Name of witness) (Name of client)

place/his/her mark or signature on this document. I am satisfied that he/she

understands the contents herein.

(Signature of witness)

I wish to place the following restrictions on the release of this information:

Addendum B – Authorization for Direct Deposit

Multiple Sclerosis Society

Ontario Division Clients

AUTHORIZATION FOR DIRECT DEPOSIT

PLEASE PRINT ALL INFORMATION

Client Name: ______

Client Address: ______

______

______

______

Authorization:

I authorize direct deposit via electronic fund transfer for payments from the MS Society and have included a voided cheque for the account that payment should be remitted to.

______

Authorized Signature:

REMEMBER TO ATTACH A VOIDED CHEQUE TO THIS FORM

PLEASE DO NOT FAX

Information collected on this form shall only be used for the purpose of setting up direct deposit via electronic funds transfer for payments by the MS Society and shall be maintained in strict confidence. Any questions relating to information required on this form or the direct deposit process should be directed to the Grand Erie Chapter at 519-758-5175.

The Bedolfe Grant Application Page 6 of 6

Updated January 2, 2017